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These are instructions for my health care when I am unable to make and communicate health care decisions for myself. These instructions must be followed (so long as they address my needs).
______ (Declarant's initials) I direct that life-prolonging treatment be withheld or withdrawn and that I be permitted to die naturally if two physicians certify that:
(a) I am in a terminal condition that is an incurable or irreversible condition which, without the administration of life-prolonging treatment, will result in my imminent death;
(b) The application of life-prolonging treatment would serve only to artificially prolong the process of my dying; and
(c) I am not pregnant
OR
if two physicians certify that I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
It is my intention that this declaration be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and that they accept the consequences of that refusal, which is death.
______ (Declarant's initials) I direct that life-prolonging treatment, which could extend my life, be used if two physicians certify that I am in a terminal condition that is an incurable or irreversible condition which, without the administration of life-prolonging treatment, will result in my imminent death. It is my intention that this declaration be honored by my family and physicians as the final expression of my legal right to direct that medical or surgical treatment be provided.
______ (Declarant's initials) I make no statement concerning life-prolonging treatment.
______ (Declarant's initials) I wish to receive nutrition.
______ (Declarant's initials) I wish to receive nutrition unless I cannot physically assimilate nutrition, nutrition would be physically harmful or would cause unreasonable physical pain, or nutrition would only prolong the process of my dying.
______ (Declarant's initials) I do not wish to receive nutrition.
______ (Declarant's initials) I make no statement concerning the administration of nutrition.
______ (Declarant's initials) I wish to receive hydration.
______ (Declarant's initials) I wish to receive hydration unless I cannot physically assimilate hydration, hydration would be physically harmful or would cause unreasonable physical pain, or hydration would only prolong the process of my dying.
______ (Declarant's initials) I do not wish to receive hydration.
______ (Declarant's initials) I make no statement concerning the administration of hydration.
However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-prolonging procedures, it is my preference that this document be given effect at that point. If life-prolonging procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant. I want to receive pain relieving medication or treatment without regard to its affect on my alertness. I want to receive pain relieve medication and be kept comfortable even if it could shorten my life. I DO NOT want to receive pain relieving medication or treatment if it will significantly affect my ability to be alert and communicate in my final days. I DO NOT want to receive pain relieve medication if it could shorten my life. I want my Health Care Agent to make all decisions regarding the donation of my organs and tissue. I wish to donate any needed organs and tissue. only the following organs and tissue: .| Birthdate: |
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
NOTARY PUBLIC
. DURABLE POWER OF ATTORNEY FOR HEALTH CARE
I UNDERSTAND THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS FOR ME IF I AM UNABLE TO MAKE AND COMMUNICATE HEALTH CARE DECISIONS FOR MYSELF (I know I can change my agent or alternate agent at any time and I know I do not have to appoint an agent or an alternate agent)
I authorize my Agent to make the final decisions regarding the disposition of my body after death including funeral preparations and decisions regarding burial and cremation. This Durable Power of Attorney for Health Care will exist until it is revoked.Unless you specify a shorter period in the space below, this Durable Power of Attorney for Health Care will exist until it is revoked.
This Durable Power of Attorney for Health Care expires on .
SECOND ALTERNATE AGENT
| Agent Name: |
| Address: |
| , |
| Phone: | Home: Work: |
I sign my name to this on the _____ day of ____________________, _____, at , North Dakota.
I sign my name to this Declaration and Durable Power of Attorney for Health Care on the _____ day of ____________________, _____, at , North Dakota.
| Birthdate: |
STATEMENT OF WITNESSES
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
| Name: |
| Address: |
| , |
| Name: | ________________________________ |
| Address: | ________________________________ |
| ________________________________ |
| ________________________________ |
NOTARY PUBLIC
__________________
Date
________________________________________
PRINCIPAL'S STATEMENT
I have read a written explanation of the nature and effect of an appointment of a health care agent that is attached to my health care directive.
_________________
Date
_____________________________________
| (Signature of Principal) |
| _____ | Your Agent, , must sign this form. |
| _____ | North Dakota requires that special provisions within the document be separately initialed or signed. |
| _____ | (your Agent) |
| * | You should discuss the document and your wishes with any person you want to designate as an Agent before doing so to assure they agree to act on your behalf. |
Outline your last wishes in North Dakota
Make a Power of Attorney in North Dakota
Appoint a healthcare agent in North Dakota
Outline your medical wishes in North Dakota
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It's fast and simple to outline your medical preferences with a free North Dakota Living Will template from Rocket Lawyer:
This route is often much less expensive than hiring a conventional lawyer. If necessary, you may prepare this Living Will on behalf of a family member, and then have them sign it when ready. Please remember that for a Living Will to be considered legally valid, the principal must be a mentally competent adult when they sign. In the event that the principal is already incapacitated and unable to make their own decisions, a conservatorship might be necessary. In this scenario, it's important to speak to an attorney .
Everyone over 18 years old ought to have a Living Will. Although it's difficult to think about, a time may come when you aren't able to make medical decisions on your own. Typical situations where it may be useful to make or update your Living Will include:
Whether your North Dakota Living Will has been generated as part of a long-term plan or made as a result of a change in your health, witnesses and notarization are strongly encouraged as a best practice for protecting this document and your agent if someone disputes their power and authority. In North Dakota, a Living Will is not valid during pregnancy.
Making a Living Will is normally simple; however, you or your agent(s) could have legal questions. Having an attorney look over the document may take a long time if you do it alone. An easier approach might be to request help from the Rocket Lawyer attorney network. Premium members are able to request advice from an attorney with relevant experience or pose other legal questions. As always, you can be confident that Rocket Lawyer is here by your side.
The cost of finding and working with your average legal provider to draft a Living Will might add up to anywhere between two hundred and one thousand dollars, depending on where you are. When you use Rocket Lawyer, you aren't just filling out a Living Will template. If you ever require support from a lawyer, your membership offers up to a 40% discount when you hire an attorney from our Rocket Lawyer attorney network.
With a Premium membership, you may make edits, save it as a Word or PDF document, or print it. When you are ready to finish up your North Dakota Living Will form, it will need to be signed. You will need to send a copy of your fully signed document to your agent(s), care providers, and other impacted parties.
The specific guidelines and restrictions for Living Wills will vary in each state; however, in North Dakota, your document needs to be signed by a notary public or two witnesses. At least one witness to your Living Will form must not be anyone providing you with direct health care or long-term care, or any employee of such a provider. Family members (including your spouse or adoptees), heirs, and beneficiaries also cannot be witnesses. As a basic rule, witnesses will need to be at least 18 years old, and no witness should simultaneously be your healthcare agent.
